SAUNDERS COMPREHENSIVE REVIEW FOR THE
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1 — Single-best-answer (triage category)
A 62-year-old man arrives at triage after a motor vehicle
collision. He is awake but confused, respirations 30/min with
shallow chest rise, bilateral decreased breath sounds on the
left, and systolic BP 80 mm Hg. Which triage category is most
appropriate?
A. Non-urgent (green)
B. Urgent / delayed (yellow)
C. Emergent / immediate (red)
D. Expectant (black)
Correct answer: C — Emergent / immediate (red)
Rationale: The client is hemodynamically unstable (SBP 80 mm
Hg), tachypneic with shallow respirations, and altered mental
,status — all cues indicating life- or limb-threatening injuries
requiring immediate interventions (airway, breathing,
circulation). In triage systems used in EDs and mass casualty,
unstable vital signs + altered LOC = immediate (red).
Distractors:
A. Non-urgent is for stable, minor injuries.
B. Urgent/delayed applies to serious injuries that can wait (e.g.,
closed fractures, stable vitals).
D. Expectant reserved for those unlikely to survive given
available resources (e.g., no respirations after airway
repositioning in MCI).
2 — NGN-style: sequential cue recognition (ordered response)
Order these actions for the same patient in Q1 (1 = first action,
4 = last):
A. Apply chest tube to the left pleural space if
tension/pneumothorax suspected.
B. Open airway and provide high-flow oxygen / assist
ventilations.
C. Obtain large-bore IV access and begin fluid resuscitation.
D. Rapid trauma assessment / logroll to check for spinal injury.
Correct order: B → C → A → D
Rationale: Airway and oxygenation are the immediate priorities
(A in ACLS/ATLS sequence). After ensuring airway and
oxygenation (B), address circulation with IV access and
,fluids/blood (C). Chest decompression (A) follows if clinical signs
of tension pneumothorax or massive hemothorax are present
— this may be simultaneous with C when indicated. Rapid
trauma assessment (D) is necessary but secondary to stabilizing
ABCs in the initial seconds/minutes. This ordering reflects
advanced life support and trauma triage priorities.
3 — Single-best-answer (START triage cue)
During a mass-casualty incident using START triage, a walking,
conscious adult is moving about the scene. Which triage
tag/color is appropriate?
A. Red (immediate)
B. Yellow (delayed)
C. Green (minor)
D. Black (expectant)
Correct answer: C — Green (minor)
Rationale: START’s first simple action is to ask “If you can walk,
move to…” Those who can ambulate are considered walking
wounded (green/minor). Red applies to immediate life-
threatening injuries; yellow for serious but delayed; black for
deceased/expectant. START is widely used for primary field
triage in MCIs. CHEMM+1
4 — Single-best-answer (chemical exposure initial step)
, An unresponsive adult is brought to the ED after being
evacuated from a chemical spill. He is coughing and has skin
contamination. What is the nurse’s immediate priority?
A. Begin IV fluids.
B. Move the patient to the decontamination area and remove
clothing.
C. Administer nebulized bronchodilator.
D. Obtain ABG and chest x-ray.
Correct answer: B — Move the patient to the decontamination
area and remove clothing.
Rationale: For chemical exposures, rapid removal of
contaminated clothing and decontamination (e.g., showering)
reduces ongoing absorption and protects healthcare staff.
Decontamination ideally occurs as soon as possible (within
minutes if feasible). Resuscitation continues, but preventing
further chemical exposure is urgent. Subsequent interventions
(IV fluids, bronchodilator) follow decontamination and
assessment. CDC+1
5 — Single-best-answer (CPR algorithm - adult)
A bystander witnesses an adult collapse and calls 911. The
patient is unresponsive and gasping. What is the nurse’s best
immediate action?
A. Check carotid pulse for 30–60 seconds.
B. Begin high-quality chest compressions immediately.
NCLEX-PN® EXAMINATION
9TH EDITION
• AUTHOR(S)LINDA ANNE SILVESTRI; ANGELA
SILVESTRI
EMERGENCY NURSING AND TRIAGE (CRITICAL &
URGENT CARE) TEST BANK.
1 — Single-best-answer (triage category)
A 62-year-old man arrives at triage after a motor vehicle
collision. He is awake but confused, respirations 30/min with
shallow chest rise, bilateral decreased breath sounds on the
left, and systolic BP 80 mm Hg. Which triage category is most
appropriate?
A. Non-urgent (green)
B. Urgent / delayed (yellow)
C. Emergent / immediate (red)
D. Expectant (black)
Correct answer: C — Emergent / immediate (red)
Rationale: The client is hemodynamically unstable (SBP 80 mm
Hg), tachypneic with shallow respirations, and altered mental
,status — all cues indicating life- or limb-threatening injuries
requiring immediate interventions (airway, breathing,
circulation). In triage systems used in EDs and mass casualty,
unstable vital signs + altered LOC = immediate (red).
Distractors:
A. Non-urgent is for stable, minor injuries.
B. Urgent/delayed applies to serious injuries that can wait (e.g.,
closed fractures, stable vitals).
D. Expectant reserved for those unlikely to survive given
available resources (e.g., no respirations after airway
repositioning in MCI).
2 — NGN-style: sequential cue recognition (ordered response)
Order these actions for the same patient in Q1 (1 = first action,
4 = last):
A. Apply chest tube to the left pleural space if
tension/pneumothorax suspected.
B. Open airway and provide high-flow oxygen / assist
ventilations.
C. Obtain large-bore IV access and begin fluid resuscitation.
D. Rapid trauma assessment / logroll to check for spinal injury.
Correct order: B → C → A → D
Rationale: Airway and oxygenation are the immediate priorities
(A in ACLS/ATLS sequence). After ensuring airway and
oxygenation (B), address circulation with IV access and
,fluids/blood (C). Chest decompression (A) follows if clinical signs
of tension pneumothorax or massive hemothorax are present
— this may be simultaneous with C when indicated. Rapid
trauma assessment (D) is necessary but secondary to stabilizing
ABCs in the initial seconds/minutes. This ordering reflects
advanced life support and trauma triage priorities.
3 — Single-best-answer (START triage cue)
During a mass-casualty incident using START triage, a walking,
conscious adult is moving about the scene. Which triage
tag/color is appropriate?
A. Red (immediate)
B. Yellow (delayed)
C. Green (minor)
D. Black (expectant)
Correct answer: C — Green (minor)
Rationale: START’s first simple action is to ask “If you can walk,
move to…” Those who can ambulate are considered walking
wounded (green/minor). Red applies to immediate life-
threatening injuries; yellow for serious but delayed; black for
deceased/expectant. START is widely used for primary field
triage in MCIs. CHEMM+1
4 — Single-best-answer (chemical exposure initial step)
, An unresponsive adult is brought to the ED after being
evacuated from a chemical spill. He is coughing and has skin
contamination. What is the nurse’s immediate priority?
A. Begin IV fluids.
B. Move the patient to the decontamination area and remove
clothing.
C. Administer nebulized bronchodilator.
D. Obtain ABG and chest x-ray.
Correct answer: B — Move the patient to the decontamination
area and remove clothing.
Rationale: For chemical exposures, rapid removal of
contaminated clothing and decontamination (e.g., showering)
reduces ongoing absorption and protects healthcare staff.
Decontamination ideally occurs as soon as possible (within
minutes if feasible). Resuscitation continues, but preventing
further chemical exposure is urgent. Subsequent interventions
(IV fluids, bronchodilator) follow decontamination and
assessment. CDC+1
5 — Single-best-answer (CPR algorithm - adult)
A bystander witnesses an adult collapse and calls 911. The
patient is unresponsive and gasping. What is the nurse’s best
immediate action?
A. Check carotid pulse for 30–60 seconds.
B. Begin high-quality chest compressions immediately.
